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Dc Revised Ears Nose Throat Mouth Part 2

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  • 1. Ears, Nose, Mouth, Throat
  • 2. Ears
  • 3. Anatomy
    • The ear is responsible for hearing and balance
    • Consists of 3 regions
      • External ear
      • Middle ear
      • Inner ear
  • 4. Structure and Function
    • External Ear
    • > auricle/pinna
    • - movable cartilage covered with skin
    • - Mastoid process= important Landmark
    • External Auditory Canal
    • - S-shaped pathway leading to the ME
    • - 2.5 to 3 cm. long in adult
  • 5.
    • Its skeleton of bone and cartilage is covered with sensitive skin ( outer 1/3 is cartilage, inner 2/3 consists of bone)
    • This canal lining is protected and lubricated with cerumen
  • 6.  
  • 7.
    • - Lymphatic drainage of the external ear flows into parotid , mastoid, superficial cervical nodes
  • 8.  
  • 9. MIDDLE EAR
    • > air filled cavity in the temporal bone
    • >It contains the ossicles ( malleus, incus,stapes) that transmit sound from the TM to the oval window of the inner ear
  • 10. MIDDLE EAR
    • >Tympanic membrane (eardrum) separates external and middle ear.
      • Translucent membrane
      • Pearly, gray color
      • Cone of light reflection when using otoscope
      • Oval and slightly concave shape, pulled in at center by malleus
  • 11. Middle ear
    • >Openings to
        • Outer ear covered by tympanic membrane
        • Inner ear = oval and round windows
        • Eustachian tube connects middle ear to the nasopharnyx for air passage (normally closed, opens with swallowing/yawning)
  • 12.  
  • 13.  
  • 14. Middle ear has 3 functions
    • Conducts sound vibration from outer ear to inner ear
    • Protects the inner ear by reducing the amplitude of loud sounds
    • Eustachian tube allows equalization of air pressure on each side of the ear drum to avoid rupture ( high altitudes)
  • 15. Inner Ear
    • Contains the Bony Labyrinth which holds the sensory organs for hearing and equilibrium
      • Vestibule
      • Semicircular canals
      • Cochlea (contains the central hearing apparatus)
  • 16.  
  • 17. Function of hearing
    • 3 levels
      • Peripheral
      • > ear transmits sound and converts its vibrations into electrical impulses
      • > The electrical impulses are conducted by the auditory process of cranial nerve VIII (Acoustic) to the brain stem
        • Amplitude=loudness
        • Frequency=pitch
  • 18.
    • Sound waves cause the eardrum to vibrate
    • > Vibrations travel via the ossicles thru the oval window > the cochlea > to the round window where they are dissipated
  • 19.
    • Vibrations in the basilar membrane of the cochlea that contain the organ of Corti receptor hair cells > translate the vibrations to electric impulses
    • > The stimulated impulses go to the brainstem via Acoustic nerve (VIII)
  • 20.
    • 2. Brain stem
    • permits identification of sound and locating the direction of a sound in space.
    • Sensitive to intensity and timing from the ears
    • depending on head position
    • 3. Cerebral cortex
    • - Intreprets the meaning of the sound and begins the appropriate response
  • 21. Pathways of hearing
    • Air conduction (AC)– normal pathway of hearing, the most efficient
    • Bone conduction (BC)– bones of the skull vibrate and transmit vibrations to the inner ear and acoustic nerve
  • 22.  
  • 23.  
  • 24. Physical Examination
    • The Auricle
    • 1) inspect each auricle for size , shape, symmetry, color, position on the head, deformities, nodules and lesions
    • 2) If ear pain, discharge or inflammation is
    • present, move the auricle up and down
  • 25.
    • 3 ) Note tenderness of pinna and mastoid area. Press the tragus and press firmly behind the ear
  • 26. Physical Examination
    • Auricle
    • -Extends slightly outward from the skull
    • Positioned in a nearly vertical plane
    • The origin of the helix should be on a horizontal line with corner of the eye
    • It should have the same color as the facial skin w/o moles, cysts & other lesions
  • 27. Otoscopic Exam
    • 1) Tip the patient’s head to the opposite side
    • 2)Grasp the auricle firmly but gently, while pulling it upward, backward and slightly outward
    • 3)Insert into the canal, sl down and forward, the largest ear speculum that the canal will accommodate
  • 28.  
  • 29.  
  • 30.  
  • 31.
    • 4) Observe the ff:
    • - patency of the ear canal
    • - describe the walls of the ear canal. Note
    • any redness or swelling
    • - identify any discharge, presence of cerumen or FB in the ear canal
    • - tympanic membrane
  • 32. Inspect using Otoscope
    • External canal
      • Color
      • Swelling
      • Lesions
      • Discharge ; color and odor. Clean or change speculum before examining other ear.
  • 33. Tympanic membrane
    • Color – normal is shiny, translucent, pearl-grey
    • Landmarks ( umbo, handle of malleus, light reflex)
    • Position – flat, slightly pulled in at the center and flutters when person holds nose and swallows
    • Integrity of membrane – intact
  • 34.  
  • 35.
    • Perform the otoscope exam prior to hearing tests.
  • 36. Hearing Evaluation
    • Rough quantitative test for hearing loss
    • Whisper test
    • Tuning fork
  • 37.
    • Rough quantitative test for hearing loss
    • - begins when the patient responds to your questions and directions. The patient responds without excessive requests for repetition
    • - Speech with a monotonous tone and erratic volume may indicate hearing loss
  • 38. WHISPER TEST
    • Begins with the history-Conversational tone
    • The following tests may indicate the presence of hearing loss but not the degree.
  • 39.
    • Place your mouth at the side of the patient’s head ( 2 ft.) from her ear with the far ear covered
    • Whisper test questions that can’t be answered by yes or no
    • Test consistently with loud, medium and soft tones
  • 40.
    • Repeat on the opposite ear using another word, have the client identify the words (Used to detect high-tone loss)
    • Normal Response to Voice test
      • Correct identification of whispered words bilaterally
  • 41. TUNING FORK TESTS
    • Measure hearing by air conduction and bone conduction
    • Frequency of fork is 256-1024 cycles/sec.
    • To activate the tuning fork, hold it by the stem and strike the tines softly on the back of the hand
  • 42. TUNING FORK TEST
    • Weber test
    • > used when hearing is reported as better in one ear than the other ( bone conduction)
    • > with normal neurosensory hearing and no conductive loss, the sounds are equal in both ears
  • 43.
    • > lateralization of the sound to one ear indicates a conductive loss on the same
    • side or a perceptive loss/sensorineural loss on the other side
  • 44.
    • Weber Test
  • 45.
    • Rinne test – compares bone conduction and air conduction
      • Normally sound is heard 2X as long by air conduction as by bone conduction
      • Normal response ; positive Rinne Test = AC>BC Bilaterally
      • Sound is heard longer by BC with a conductive loss.
  • 46.
    • Rinne Test
  • 47. Weber test Rinne test
  • 48. Summary of any symptom should include PQRSTU
    • P= provocative or palliative
    • Q= quality or quantity
    • R= region or radiation
    • S= severity scale
    • T= timing (onset, duration, frequency)
  • 49. Subjective data
    • Earaches
    • Tinnitus
    • Vertigo
    • Dizziness
    • Discharge
    • Hearing loss
  • 50. HISTORY
    • Always ask the following:
    • Tinnitus –ringing in the ears
    • causes:
    • a.Outer ear- cerumen, foreign body,polyp
    • in the external auditory canal
    • b. Middle ear – inflammation ,otosclerosis
    • c. Internal ear- fever, suppuration of the
    • labyrinth, SY,acoustic nerve tumor
  • 51.
    • internal ear – fracture at the base of the skull, meniere syndrome
    • d.Drugs
    • quinine, salicylates, aminoglycosides, gentamicin
  • 52.
    • Ear pain ( Otalgia )
    • - pain may arise from inflammation of structure in the ear or be referred from other pharyngeal sites including the thyroid
  • 53.
    • Causes:
    • Auricle- trauma,hematoma,frostbite,burn,eczema,
    • lnsect bites, impetigo, herpes zoster
    • External auditory canal-
    • otitis externa ,carbuncle, eczema, hard cerumen, FB, herpes zoster
  • 54.
    • Middle ear-
    • acute otits media, acute mastoiditis
    • Referred pain- unerrupted lower third molar, carious
    • teeth, tonsillitis, carcinoma of pharynx, trigeminal neuralgia , subacute thyroiditis
  • 55.
    • Dizziness
    • - patient has a sense of disturbed relation to space
    • - described as being unsteady, weak, light headed or having the feeling of turning
    • Causes:
    • Endocrine
    • hypothyroidism,pregnancy, hypoparathyroidism
  • 56.
    • Idiopathic
    • multisystem atrophy
    • Infectious
    • tabes dorsalis, meningitis, encephalitis, brain abscess
    • Metabolic/ nutritional
    • pellagra, Vit.B12 def.,fluid & electrolyte imbalance
  • 57.
    • Mechanical/trauma
    • skull fracture, otosclerosis, eye muscle imbalance glaucoma
    • Neoplastic
    • Brain tumors
    • Neurologic
    • migraine, peripheral neuropathy
    • Psychosocial
    • anxiety disorder
    • Vascular
    • hypertension, orthostatic hypotension
  • 58.
    • Vertigo
    • - persistent stimulation of the semicircular
    • canals or vestibular nucleus when the
    • head is at rest
    • It gives a hallucination of motion
    • When the eyes open, the pts.surrounding
    • seems to be whirling or spinning
    • - When the eyes closed, the pt.continues to feel in motion
  • 59.
    • Causes:
    • Peripheral labyrinthine System
    • - otitis media with effusion, otosclerosis,
    • temporal bone fracture
    • Central labyrinthine system
    • - migraine, cerebellar hemorrhage, intracranial abscess
  • 60.
    • Cranial V111 infections
    • - Acute meningitis, tuberculous meningitis, tumors
    • Brainstem nuclei
    • - encephalitis, brain abscess, hemorrhage, multiple sclerosis
  • 61.
    • Hearing loss
    • a. Conductive- seen in people with external or middle ear problem
    • Causes:
    • -obstruction of external auditory canal (FB, impacted cerumen)
    • Disorder of the eardrum & middle ear ( perforated TM, pus/blood in the ME )
    • Overgrowth of bone with fixation of the stapes ((Otosclerosis)
  • 62.
    • b. Sensorineural hearing loss ( Perceptive)
    • - involves the inner ear
    • Causes:
    • - disorders of the cochlea or the acoustic nerve (CN 8)
    • Aging ( Presbycusis ) due to nerve degeneration
    • Trauma
    • Drug toxicity
    • Tumors
    • infections
    • Heredity/congenital deafness
  • 63. EAR SIGNS
    • EXTERNAL EAR
    • Malformations of the Pinna
    • microtia – smaller than normal
    • macrotia – unusually large
    • lop or bat ear- pinna may protude at R angle
    • aztec or cagot ear – failure of
    • development of the lobule
  • 64. Macrotia or large ear Before Surgery After Surgery
  • 65. Before Surgery After surgery
  • 66.
    • Lop or Bat ear
    • - pinna may protrude at right angle
  • 67. Lop or Bat Ears
  • 68.
    • satyr ear- pointed pinna
    • cauliflower ear- untreated hematomas heal as nodular and bulbous irregularities of the helix and and antihelix
    • - result of blunt trauma and
    • necrosis of the underlying
    • cartilage
  • 69. Cauliflower Ears
  • 70.
    • b ) Pinna nodule
    • Darwin tubercle- harmless developmental
    • eminence in the upper 3 rd
    • of the posterior helix
    • Gouty tophus – small, whitish uric acid
    • crystals along the
    • peripheral margins of the
    • auricles, olecranon bursa, tendon sheaths
    • - nodules are painless hard, and irregular
  • 71. Gouty deposits
  • 72.
    • b)External acoustic meatus
    • Cerumen Impaction
    • - due to excessive production of wax or a narrowed meatus leads to partial or complete obstruction of the canal
    • - complete obstruction leads to partial deafness acc. by tinnitus or dizziness
  • 73.
    • Otorrhea( ear discharge)
    • yellow discharge- melted cerumen
    • serous discharge- eczema in the meatal
    • wall, early ruptured acute OM
    • bloody discharge- temporal bone fracture
    • purulent discharge- chronic external otitis,
    • chronic suppurative OM,
    • cholesteatoma, TB, polyps
  • 74.
    • Foreign body
    • Insect invaders
    • Polyps
    • Furuncle
  • 75.
    • Tympanic membrane
    • Retracted Tympanic membrane :
    • - Seen in Serous Otitis media
    • - more concave TM
    • - accentuated bony landmarks
    • - distorted light reflex
  • 76. Normal Tympanic Membrane Retracted Tympanic Membrane
  • 77.
    • Bulging Tympanic membrane:
    • seen in Acute suppurative otitis media
    • more conical
    • loss of bony landmarks
    • distorted light reflex
  • 78. Normal Tympanic Membrane Bulging Tympanic Membrane
  • 79.
    • Perforated Tympanic membrane:
    • - previous suppurative middle ear infection has eroded thru the membrane producing
    • holes
    • - perforation appears as oval holes thru which the darkened middle ear cavity is seen
  • 80. Perforated Tympanic Membrane
  • 81. Perforated Tympanic Membrane
  • 82. COMMON DISORDERS OF THE EAR
    • Otitis Externa
    • a) Acute external otitis
    • -due to Ps.aeruginosa, staph, strep, proteus
    • - pain maybe mild or severe accentuated by movement of the pinna
    • - swimmers’ ear
    • - preauricular, postauricular , Ant cervical LN
  • 83.
    • b) Chronic external otitis
    • - commonly due to bacteria and fungal
    • - pruritus is the main complain instead of pain
    • - aural discharge maybe present
  • 84.
    • Otitis Media
    • a) Chronic suppurative otitis media
    • - ass. with permanent perforation of the eardrum
    • -hearing is always impaired
    • - painless aural discharge
    • - pain and vertigo indicates development of complications like brain abscess
  • 85.
    • b) Cholesteatoma
    • - collection of desquamated epithelial cells in the middle ear
    • - foul smelling discharge, marginal
    • perforation,hearing loss, pearly gray mass
    • superior part of tympanic membrane
    • - eustachian tube dysfunction causes
    • retraction of tympanic membrane
  • 86.
    • Vertiginous disorder
    • Acute Labyrinthitis
    • - most frequent cause of vertigo
    • - patient gradually develop a sense of whirling that reaches a climax in 24-48 hrs. disappear gradually in 3-6 wks.
    • - N/V may occur at the height of symptoms
    • - no accompanying tinnitus or hearing loss
  • 87.
    • b) Benign Paroxysmal positional Vertigo
    • (BPPV)
    • Calcium deposits in the labyrinth ( otoliths)
    • are dislodged and move in response to gravity eliciting a feeling of motion
    • More common in older individuals
    • Sudden onset, often when rolling over in bed or arising in the morning
    • No headaches/fever but with nausea and inability to stand
    • Avoid any head motion to lessen symptoms
  • 88. Thank You
  • 89. Nose, Throat and Mouth
  • 90. Nose
    • First segment of the respiratory system
    • Warms, moistens and filters inhaled air
    • Sensory organ for smell
    • Resonance of laryngeal sound
  • 91.  
  • 92. External parts
    • Bridge – frontal and maxillary bones
    • Tip
    • Nares – anterior openings of the nos
    • Columella - divides the nares
    • Ala nasi –lateral outside wing of the nose bilaterally
    • Upper 1/3 nose is bone; rest is cartilage
  • 93. Internal
    • Nasal cavity
    • -floor of the nose ( hard and soft palate)
    • - roof of the nose ( frontal and sphenoid bone)
    • Nasal hair
    • Nasal Septum-divides cavity into 2 passages
    • Nasal turbinates
  • 94. Internal
    • Superior, middle, inferior turbinates- 3 parallel bony projections on lateral walls of each cavity
    • Meatus- cleft/ groove underlying each turbinate.
  • 95.
    • Inspired air enters thru the nares > passes thru the vestibule> to the choanae which are posterior openings > leading to the nasopharynx
  • 96. Internal
    • Olfactory receptors
    • - roof of the nasal cavity & upper part of septum above the superior turbinate.
    • -merge into the olfactory nerve (I) > goes to the temporal lobe of the brain
    • Kiesselbach plexus
    • - a vascular network located superficially on the anterior superior portion of the septum
    • - site of most anterior nosebleeds
  • 97.  
  • 98. SINUSES
    • Paranasal sinuses
    • - air-filled paired extensions of the nasal cavities within the bones of the skull
    • - lined with mucous membranes and cilia that move secretions along excretory pathways
    • - sinus openings are narrow, susceptible to occlusion> resulting in inflammation /sinusitis.
    • - drained into the medial meatus
  • 99.
    • Purpose
      • Serve as resonators for sound
      • Provide mucous for the nasal cavity
      • Types:
      • Frontal sinuses
      • Maxillary sinuses
      • Ethmoid sinuses
      • Sphenoid sinuses
      • Frontal & Maxillary sinuses are accessible to examination
  • 100.  
  • 101.  
  • 102. Physical Examination
  • 103.
    • Nose – Inspect and
    • palpate
    • INSPECT for:
      • Symmetry, deformity
      • Inflammation
      • Skin lesions
      • Color
      • Nasal flaring
      • discharges
  • 104.
    • Palpate
    • - ridge & soft tissues of the nose
    • - note any displacement of the bone,
    • cartilage
    • - note for tenderness & any mass
    • - The nasal structures should be firm and stable to palpation
    • - if with injury, palpate gently
  • 105.
    • Test for sense of smell (CN 1)
    • Evaluate the patency of the nose
    • - nasal breathing should be noiseless and easy thru the open nares
  • 106. Nasal Cavity
    • Use the nasal speculum and good light source to inspect the nasal cavity
    • Nasal mucosa
    • - inspect for color, discharge, lesions, masses
    • - it should appear deep pink ( pinker than the buccal mucosa) & glistening
  • 107.
    • b) nasal septum
    • - In normal adult, the nasal septum is seldom precisely a midline structure
    • - No perforations, bleeding or crusting should be apparent
    • - a film of clear discharge is often apparent on the nasal septum
  • 108.
    • c) Nasal Turbinates
    • - only the inferior and middle turbinates will be visible
    • - it should be the same color as the surrounding area and have a firm consistency
  • 109.  
  • 110.
    • Paranasal Sinuses: Inspect and Palpate
      • Press thumbs over frontal & maxillary sinuses ( palpate the cheeks and supraorbital ridges)
      • No tenderness or swelling over the soft tissue should be present
  • 111.
    • Transillumination test
    • a) Frontal & Maxillary sinuses
      • b) nasal septum
      • Best perform in a dark room
      • Look for a bright light in the supraorbital ridge
      • and maxilla
      • Look for deviation, perforation, masses in the
      • transilluminated septum
  • 112.  
  • 113.  
  • 114.  
  • 115.  
  • 116. SYMPTOMS
    • Loss of smell ( anosmia )
    • - lesion of CN 1 or nasal obstruction
    • - commonly due to closed head trauma
    • - invariably accompanied by a perceived change in taste of food ( bland & unpalatable)
  • 117.
    • Abnormal smell/ taste (dysgeusia)
    • - this is a common complaint in patients who have loss of smell
    • - if it is paroxysmal and associated with behavioral symptoms, it suggests complex partial seizures
  • 118. SIGNS SKIN LESIONS
  • 119. Basal Cell Carcinoma
  • 120. SIGNS
    • Discharge
    • - Describe discharge as to its character
    • ( watery, mucoid, purulent , bloody)
    • - color ( greenish, whitish, bloody)
    • - bilateral or unilateral
  • 121.
    • Running Nose
  • 122.  
  • 123.
    • . 1.Unilateral
    • - Choanal atresia
    • - Foreign body- foul purulent discharge
    • - neoplasm – bloody discharge
    • - Head injury or surgery – clear spinal fluid
    • 2. Bilateral
    • - allergy
    • - infection ( upper respiratory)
  • 124. Foreign Body
  • 125. . Unilateral - Choanal atresia - Foreign body - neoplasm - Head injury or surgery . Unilateral - Choanal atresia - Foreign body - neoplasm - Head injury or surgery
  • 126.
    • Epistaxis ( nosebleed)
    • -Kiesselbach plexus – most common site of bleeding anteriorly
    • - Back 3 rd of the Inferior Meatus – most common site posteriorly
  • 127.
    • Causes:
    • Local
    • - coughing
    • - sneezing
    • - nose pricking
    • - fracture
    • - foreign bodies
  • 128.
    • 2. Generalized
    • - Congenital – hereditary telangiectasia
    • - inflammatory/immune – wegener
    • granulomatosis
    • - infectious – typhoid fever, dengue,
    • diphtheria
    • - Metabolic/toxic – aspirin, scurvy
  • 129.
    • Mechanical – change in atmospheric
    • pressure ( mountain climbing, flying), exertion
    • Neoplastic – nasopharyngeal Ca
    • leukemia
    • vascular- hemophilia, thrombocytopeni
  • 130.
    • trauma- nasal and maxillary fracture
    • Elevated venous pressure- Cor pulmonale Congestive Heart failure
    • Elevated arterial pressure – HPN,
    • coarctation of aorta
  • 131.
    • Nasal septum
    • a) Deviation
    • - the cartilagenous and bony septum
    • may deviate as a hump, spur, shelf to
    • enroach on one nasal chamber
    • occlusion causing obstruction
  • 132.
    • b) Perforation
    • - a hole in the nasal septum (transillumination test) is commonly caused by chronic infection, nasal surgery,
    • repeated trauma in picking off crusts,
    • cocaine abuse
    • - rarely due to SY, TB
  • 133. Nasal Septum Perforation
  • 134. Nasal Syndromes
    • Acute Rhinitis ( infectious) ( common cold)
    • Rhinoviruses infect the mucous membranes of the nose & sinuses causing inflammation and inc. nasal secretions
    • - Watery nasal discharge, sneezing, discharge becomes purulent acc. by fever and body malaise
  • 135.
    • Symptoms 3-10 days
    • Severe local pain suggest a complication-bacterial sinusitis
  • 136.
    • Allergic rhinosinusitis
    • - itching of the nose & eyes, rhinorrhea, lacrimation, sneezing
    • - headache is common
    • - maybe seasonal or perennial
    • - common allergens are pollens, molds, house dust, mites, coachroach, animal danders
  • 137.
    • Vasomotor Rhinitis
    • - nonallergic mucosal edema and rhinorrhea ass. with vasodilatation of the nasal vessels, mucosal edema & inc. mucous production
    • - due to chronic environmental irritants
    • ( dust , smoke, strong odor, cold air),
    • pregnancy, estrogens, progesterone
  • 138.
    • Suppurative Paranasal Sinusitis
    • - due to Strep. pneumonia, H. influenza
    • - severe pain in the face occuring 7-14 days after signs & symptoms of an acute URTI
    • - pain & pressure without fever suggest sinus obstruction requiring decongestants
  • 139.
    • Cavernous Sinus Thrombosis
    • -This is the most feared complication of nasal infections. It can cause blindness or death
    • - Infection spreads from the nose>angular veins> cavernous sinus> septic thrombosis
  • 140.
    • - patient complains of pain deep in the eyes
    • - Both eyes are involved, immobilization of the globes, periorbital edema, chemosis
    • May involve CN 3,4, &6
    • Sudden chills, high fever, prostated, comatose, death within 2-3 days
  • 141. THANK YOU
  • 142. THANK YOU
  • 143. Mouth
    • First segment of the digestive system
    • Airway for the respiratory system
    • ORAL CAVITY
      • Lips
      • Palate
        • Hard
        • Soft
        • Uvula – hangs down from the soft palate
  • 144.
    • Cheeks- side walls of cavity
    • Tongue
      • Papillae- rough, bumpy elevations on dorsal
      • Frenulum
      • Taste buds
    • Teeth – 32 permanent
  • 145.  
  • 146.
    • Salivary glands
      • Parotid- largest of the glands, located in the cheeks, front of the ear. Stenson’s duct opens in buccal mucosa
      • Submandibular- walnut size, beneath the mandible at the angle of the jaw. Wharton’s duct either side of the frenulum
      • Sublingual –smallest, almond shape, under tongue
  • 147.  
  • 148. Throat
    • Area behind the mouth & nose
    • Oropharynx – separated from the mouth by a fold of tissue on each side called anterior tonsillar pillars
    • Tonsils – lymphoid tissue behind pillars
  • 149.
    • Posterior pharyngeal wall located behind the tonsils
    • Nasopharynx continues from the oropharynx but it is above it and behind the nasal cavity.
    • -It holds the adenoids and the eustachian tube openings.
  • 150.  
  • 151. Physical Examination
  • 152.
    • Preparation for examination
    • a) Face the patient with both of you seated at the same level
    • b) Remove any dentures to see the mucosa underneath
    • c) Hold the tongue blade in the left hand and penlight in the right hand
    • d) A good light source is needed
  • 153. INSPECT AND PALPATE
    • Use gloves, tongue depressor, light
    • Lips
    • Teeth
    • Gums
    • Tongue
    • Buccal mucosa
    • Mouth ( roof and floor of the mouth)
  • 154.
    • Lips
    • - remove lipstick
    • - should be pink , smooth surface, free of lesions.
    • - distinct border between the lips and facial skin should not be interrupted by lesions
    • - Vertical and horizontal symmetry both at rest and with movements
  • 155. rest Rest Movement
  • 156.
    • - Inspect the inner surface of the lips by retracting them with a tongue blade
  • 157.  
  • 158. Retraction of the Upper Lip Retraction of the lower Lip
  • 159.
    • Teeth
    • - ask patient to clench his/her teeth , smile and observe the occlusion of the teeth.
    • - facial nerve is also tested
    • Make sure teeth are firmly anchored, probing each with a tongue blade
    • Generally ivory white in color with 32 permanent teeth in adults
  • 160. Proper Occlusion of Teeth
  • 161.
    • Buccal mucosa
    • - with mouth open, using a tongue blade,
    • inspect for color, pigmentation, nodules, white patches
    • - normally pinkish red, smooth, moist
    • - orifice of the stensen duct should appear as a whitish yellow or whitish pink protrusion in alignment with the 2 nd upper molar
  • 162. Retraction of the cheek to view the Buccal Mucosa Buccal Mucosa with prominent Papilla of Stensen Duct
  • 163.
    • Gums
    • - using a tongue blade, gums should have pink appearance with clearly defined tight margin at each tooth
    • - gum surface beneath dentures should be free of inflammation, swelling or bleeding
    • - Using gloves, palpate gums for tenderness, mass, induration, thickening
  • 164.
    • Tongue
    • - should fit well in the floor of the mouth
    • - ask the patient to extend the tongue while you inspect for color, lesions, deviation, tremor, limitation of movement
    • - Ask the patient to touch the tongue tip to the hard palate area directly behind the upper central incisors. There should be no difficulty.
  • 165.
    • Inspect the dorsum of the tongue
    • it should appear dull red ,moist, glistening
    • note also for any swelling, coating, ulcerations
    • Inspect the ventral surface of the tongue
    • it should be pink and smooth with large veins bet. the frenulum and fimbriated folds
  • 166.
    • - Wharton ducts should be apparent on each side of the frenulum
  • 167.  
  • 168. Mouth
    • >Roof of the mouth
    • - hard and soft palate
    • Floor of the mouth
    • - tongue
    • Take note of the smell coming from the oral cavity
    • Ask the patient to tilt his head to inspect the palate and uvula
  • 169.  
  • 170. Uvula , soft palate, bilateral fauces
  • 171. Throat
    • Tonsils
    • - usually blend into the pink surface of the pharynx
    • - surface of the tonsils have crypts where cellular debris and food collect
    • - in normal adult, tonsils seldom protrude beyond the faucial pillars
  • 172.  
  • 173.
    • Posterior wall of the pharynx
    • It should be smooth and glistening pink mucosa with some irregular spots of lymphatic tissue and small blood vessels
    • Test CN 9 and 10
    • touch the posterior wall of the pharynx on each side
    • (+) gag reflex
  • 174.
    • Larynx
    • - immediately behind and below the oral cavity
    • - it is on the anterior wall of the pharynx
    • - it is viewed in the laryngeal mirror held behind it
  • 175. SIGNS
  • 176.
    • Lips
  • 177. Cyanotic Lips
  • 178. Chapped dry lips
  • 179.
    • > Cheilitis
    • - dry cracked lips due to dehydration from wind chapping, dentures , braces, or excessive lip licking
    • - angular cheilitis due to candidiasis
  • 180. Chapped Lips with Cheilitis
  • 181.
    • Cheilosis ( angular stomatitis)
    • - ulcerations of skin at the corners of the mouth due to crusting 2ndary to riboflavin deficiency or ill fitting dentures
  • 182. Cheilosis (Angular Stomatitis)
  • 183.
    • Cleft lip
    • - due to incomplete fusion of the frontonasal process with the 2 maxillary processes
  • 184. Cleft Lip
  • 185. Retraction of the Lower Lip showing white scars Traumatized Lip (Green arrows)
  • 186.
    • Hard palate
    Maxillary Torus
  • 187.
    • Maxillary torus
    • - bony protuberance at the midline
    • - no clinical significance
  • 188.
    • Cleft palate
    • - a midline opening in the hard palate
    • - congenital failure of the fusion of the maxillary process
    • - usually ass. with cleft palate
  • 189. Cleft Palate
  • 190.
    • Tonsils
    Enlarged tonsils
  • 191.
    • - Grading tonsillar enlargement
      • Grade size 1+ visible
      • …………… .2+ ½ way b/t tonsillar pillars and uvula
      • …………… .3+ touching the uvula
      • …………… .4+ touching each other
  • 192.
    • Uvula
    Deviation of the uvula
  • 193.
    • Posterior pharyngeal wall
    After tonsillectomy
  • 194. Posterior Pharyngeal Wall With a yellow Pseudocyst Posterior Pharyngeal Wall with White removable mass of mucus
  • 195.
    • Acute viral pharyngitis
    • - mucosa of oropharynx shows lymphoid tissue are elevated but noo edema
    • - sore throat, rhinorrhea, malaise, myalgia
    • Streptococal or staphylococcal pharyngitis
    • Pharyngeal mucosa is bright red, swollen, edematous studded with white or yellow follicles
    • Tonsils maybe enlarged
  • 196.
    • Pharyngeal diptheria
    • - patch of white membrane in the tonsils.
    • - pharyngeal mucosa bleeds on surface, reddened , reddened, swollen ,edematous
    • Candidiasis
    • - shining raised white patches on posterior pharynx, buccal mucosa and tongue
  • 197.
    • Tongue
    Lingual Deviation
  • 198. Tongue-tie or shortened frenulum
  • 199. Folliate Papillae(Green) Circumvallate Papillae(blue) Elongated filiform Papillae
  • 200. Large reddened fungiform Papillae Circumvallate Papillae
  • 201.
    • Gums
    Gingival Fibrous Nodule At the mucogingival junction
  • 202.
    • Bleeding gums
    • local causes:
    • traumatic – toothbrush, laceration, dental caries, tartar on the teeth
    • infection – pyorrhea alveolaris, stomatitis
    • neoplasm – epulis, papilloma of gums
  • 203.
    • General causes:
    • Scurvy, syphilis
    • Metal poisoning –phosporous, lead, mercury
    • Blood dyscrasia – hemophilia, leukemia, thrombocytopenia
  • 204.
    • Deep red or purple gums
    • - tender , swollen, spongy and easily bleeds
    • - due to scurvy ( ascorbic acid deficiency)
  • 205.
    • Teeth
    Malocclusion of teeth
  • 206.
    • Periodontitis ( Pyorrhea Alveolaris)
    • - lower teeth are involved
    • - with purulent and retracted gums
    • Epulis
    • - fibrous tumor arising from periosteum and emerges from between the teeth.
  • 207.
    • Larynx
    • > hoarseness
    • acute laryngitis – most common cause of hoarseness
    • > laryngeal edema
    • signs of obstruction – hoarseness, dyspnea and stridor
  • 208.
    • Laryngeal spasm
    • - acute obstruction of the upper airways accompanied by hoarse brassy cough, dyspnea in children
    • - due to allergy, infection, FB, neoplasm
    • Laryngeal paralysis
    • - Due to immobile vocal cords
  • 209.
    • Halitosis ( fetor Oris) bad breath
    • Poor hygiene
    • Dental or tonsillar infections
    • Atrophic rhinitis
    • Putrefaction of food in the stomach from pyloric obstruction
    • Infected sputum form lung abscess and bronchiectasis
  • 210. THANK YOU
  • 211.